2017 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways

• Published in: Journal of the American College of Cardiology 2017-12, Vol.70 (24), p.3042-3067
• Main Authors: Tomaselli, Gordon F, Mahaffey, Kenneth W, Cuker, Adam, Dobesh, Paul P, Doherty, John U, Eikelboom, John W, Florido, Roberta, Hucker, William, Mehran, Roxana, Messé, Steven R, Pollack, Jr, Charles V, Rodriguez, Fatima, Sarode, Ravindra, Siegal, Deborah, Wiggins, Barbara S
• Format: Article
• Language: English
• Subjects: Administration, Oral; Advisory Committees; Anticoagulants; Anticoagulants - adverse effects; Anticoagulants - therapeutic use; Atrial Fibrillation - complications; Atrial Fibrillation - drug therapy; Bleeding; Cardiac arrhythmia; Cardiology; Consensus; Decision Making; Disease Management; Hemorrhage; Hemorrhage - chemically induced; Hemorrhage - therapy; Humans; Medical treatment; Mortality; Societies, Medical; Thrombosis; United States; Venous Thrombosis - drug therapy; Venous Thrombosis - etiology
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2017.09.1085

Careful attention should be given to comorbidities that could worsen bleeding and subsequent outcome.Because of their dependence on renal function for clearance, all of the DOACs have higher blood levels and longer half lives in patients with renal dysfunction.If idarucizumab is unavailable, then either PCC or activated prothrombin complex concentrate (aPCC) at 50 U/kg (max dose 4,000 U) may be used; these measurements are based on some limited animal, ex vivo, and human studies showing variable efficacy of either agent in improving hemostatic parameters in vitro (65-71).Since dabigatran is mostly not bound to proteins in the serum (>85%), hemodialysis has been suggested if the drug level is very high, especially in patients with impaired renal function (72,73).The timing of anticoagulation reinitiation has not been systematically studied and is highly variable, although a prospective study in which anticoagulation was restarted at the time of discharge in patients with a median length of stay of 5 days (including patients in whom no source of bleeding was found) demonstrated fewer TEs at 90 days with no increase in bleeding events; in AF patients, restarting warfarin >7 days after a bleed was associated with improved survival and decreased thromboembolism without an increased risk of recurrent GI bleeding (97,98).[...]in most cases of GI bleeding, the writing committee favors reinitiation of anticoagulation in patients with an indication for OAC once bleeding has been controlled (including patients in whom no discrete source of bleeding was identified).Approximately 20% of spontaneous intracranial hemorrhage is related to anticoagulation therapy.[...]a cautious, individualized approach to restarting OAC after intracranial hemorrhage is warranted.